Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed November 17, 2023, BMA of Uniontown, was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services-Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced Medicare Re-Certification Survey completed November 17, 2023, BMA of Uniontown was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.
Plan of Correction:
494.90(a)(1) STANDARD
POC-MANAGE VOLUME STATUS
Name - Component - 00
The plan of care must address, but not be limited to, the following:
(1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient's volume status;
Observations:
Based on review of facility policy, medical records (MR), and staff (EMP) interview the facility failed to perform patient vitals and/or safety check per policy for nine (9) of nine (9) In-Center Hemodialysis MR reviewed. (MR 1-9) The facility also failed to follow policy related to monitoring patient blood pressure for four (4) of nine (9) In-Center Hemodialysis MR reviewed. (MR 2-4 & 7)
Findings Included:
Review of facility policy on 11/16/23 at approximately 8:45am revealed:
"Patient Assessment and Monitoring...During Treatment-Obtain blood pressure and pulse rate every 30 minutes or more as needed but do not exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 [minutes] or more often as needed but do not exceed 45 minutes or per state regulations...Blood Pressure...Report to the nurse: Systolic blood pressures greater than 180mm/Hg, Diastolic blood pressures greater than 100mm/Hg..."
Review of MR on 11/16/3223 between approximately 9:00am and 4:00pm revealed:
MR1, Admission date 8/3/23, dates reviewed 11/123-11/13/23.
11/1/23- Treatment record revealed 60 minutes between documented vitals checks at 8:30am and 9:30am. Treatment records also revealed 60 minutes between documented safety checks at 8:31am and 9:31am
11/6/23- Treatment record revealed 59 minutes between documented vitals checks at 6:34am and 7:33am. Treatment records also revealed 56 minutes between documented safety checks at 6:34am and 7:30am.
11/8/23- Treatment record revealed 63 minutes between documented vitals checks at 8:32am and 9:35am. Treatment records also revealed 58 minutes between documented safety checks at 8:32am and 9:30am.
11/10/23- Treatment record revealed 55 minutes between documented vitals checks at 9:35am and 10:30am.
MR2, Admission date 6/14/23, dates reviewed 11/1/23-11/13/23.
11/1/23- Systolic blood Pressure (bp) reading of 89 at 1:01pm recorded by patient care technician (PCT). No evidence of notification to Registered Nurse (RN) of findings out of facility parameters.
Treatment record revealed 60 minutes between documented vitals checks at 1:34pm and 2:34pm. Treatment records also revealed 64 minutes between documented safety checks at 1:30pm and 2:34pm.
11/3/23- Systolic bp reading of 93 at 1:03pm recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
11/6/23- Systolic bp reading of 94 at 2:02pm and 90 at 3:07pm recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
11/8/23- Systolic bp reading of 78 at 1:34pm, 95 at 2:07pm, and 97 at 2:33pm recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
11/10/23- Systolic bp reading of 98 at 12:34pm and 94 at 2:54pm, recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
MR3, Admission date 8/18/23, dates reviewed 11/1/23-11/13/23.
11/1/23- Pulse reading of 116 beats per minute at 8:30am recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
11/6/23- Bp reading of 183/147 at 6:30am. No evidence of notification to RN of findings out of facility parameters.
11/8/23- Treatment record revealed 72 minutes between documented vitals checks at 9:02am and 10:14am. Treatment records also revealed 72 minutes between documented safety checks at 9:02am and 10:14am.
11/10/23- Treatment record revealed 65 minutes between documented vitals checks at 7:30am and 8:35am. Treatment records also revealed 65 minutes between documented safety checks at 7:30am and 8:35am.
11/13/23- Treatment record revealed 57 minutes between documented vitals checks at 9:33am and 10:25am. Treatment records also revealed 55 minutes between documented safety checks at 9:30am and 10:25am.
MR4, Admission date10/24/23, dates reviewed 10/31/23-11/11/23.
10/31/23- Diastolic Bp reading of 115 at 6:10am and 114 at 9:39 am recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
Treatment record revealed 61 minutes between documented vitals checks at 7:01am and 8:02am and 91 minutes between 8:02am and 9:33am. Treatment records also revealed 60 minutes between documented safety checks at 7:00am and 8:00am and 90 minutes between 8:00am and 9:30am.
11/4/23- Treatment record revealed 60 minutes between documented vitals checks at 7:31am and 8:31am.
11/7/23- Diastolic Bp reading of 106 at 6:12am recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
11/9/23- Diastolic Bp reading of 111 at 9:02am recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
MR5, Admission date 2/23/23, dates reviewed 11/1/23-11/13/23.
11/13/23- Treatment record revealed 68 minutes between documented vitals checks at 6:26am and 7:34am. Treatment records also revealed 64 minutes between documented safety checks at 6:26am and 7:30am.
MR6, Admission date 5/30/23, dates reviewed 10/31/23-11/11/23.
10/31/23- Systolic bp reading of 91 at 7:01am, 93 at 7:30am, and 95 at 8:01am, recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
11/4/23- Diastolic Bp reading of 105 at 6:02am recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
11/7/23- Systolic bp reading of 95 at 6:31am, 95 at 7:02am, 92 at 7:33am, and 96 at 8:02am recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
11/11/23- Treatment record revealed 50 minutes between documented vitals checks at 6:10am and 7:00am.
MR7, Admission date 10/1/23, dates reviewed 10/12/23-10/26/23.
10/14/23- Systolic bp reading of 94 at 3:13pm, recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
10/19/23- Systolic bp reading of 97 at 3:03pm recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
10/21/23- Systolic bp reading of 81 at 3:03pm recorded by PCT. No evidence of notification to RN of findings out of facility parameters.
10/26/23- Treatment record revealed 60 minutes between documented safety checks at 12:00pm and 1:00pm.
MR8, Admission date 8/2/23, dates reviewed 11/1/23-11/13/23.
11/1/23- Treatment record revealed 59 minutes between documented vitals checks at 1:32pm and 2:31pm. Treatment records also revealed 60 minutes between documented safety checks at 1:32pm and 2:32pm.
11/3/12- Treatment record revealed 58 minutes between documented vitals checks at 1:02pm and 2:00pm. Treatment records also revealed 60 minutes between documented safety checks at 1:00pm and 2:00pm.
MR9, Admission date 8/2/23, dates reviewed 9/25/23-11/8/23.
10/27/23- Treatment record revealed 88 minutes between documented vitals checks at 2:32pm and 3:58pm. Treatment records also revealed 88 minutes between documented safety checks at 2:30pm and 3:58pm.
10/31/23- Treatment record revealed 50 minutes between documented vitals checks at 3:07pm and 3:57pm. Treatment records also revealed 57 minutes between documented safety checks at 3:00pm and 3:57pm.
11/3/23- Treatment record revealed 48 minutes between documented safety checks at 3:00pm and 3:48pm.
Interview with Director of Operations, Center Manager, and Home Therapies Clinical Manager on November 17, 2023 at approximately 2:00pm confirmed findings.
Repeat deficiency, previously cited: 12/18/17 & 4/24/19.
Plan of Correction:V 543
For ongoing compliance, the Clinic Manager (CM) or designee will in-service all direct patient care (DPC) staff on policy:
- Patient Assessment and Monitoring
- Nursing Supervision and Delegation
The in-service will focus on ensuring that the patient's vital signs (VS) and safety checks must be obtained per policy. The meeting will reinforce that the VS and safety checks must be taken and documented during treatment every thirty (30) minutes but not to exceed forty-five (45) minutes. The meeting will also reinforce the importance of the reporting of any VS, including blood pressures (BP) and pulse rate, that are out of acceptable range to the RN. The staff will be reminded that they must document the registered nurse (RN) notification. The meeting will review with the RN staff that they must follow up on out-of-range VS with an evaluation and intervention if indicated. The importance of documentation by the RN of the follow up will be reinforced.
In-servicing will be completed by December 5, 2023, and the training documentation will be on file at the facility.
The CM or designee will perform daily audits on twenty percent (20%) of patients flowsheets per shift for four (4) weeks. At that time if one hundred (100) % compliance is observed the audits will then be completed 2 times/week for 4 weeks. At that time, if compliance is maintained, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A plan of correction (POC) specific auditing tool will be used for the audits.
Issues of non-compliance will be addressed by the CM with re-education and counseling.
The CM will review the audit results and report the findings at the monthly QAPI meetings for ongoing oversight and compliance.
494.90(a)(1) STANDARD
POC-ACHIEVE ADEQUATE CLEARANCE
Name - Component - 00
Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.
Observations:
Based on review of facility policy, medical records (MR), and staff (EMP) interview the facility failed to ensure the blood flow rate (BFR) was administered per physician order for three (3) of nine (9) In-Center Hemodialysis records reviewed. (MR 1, 2, & 4)
Findings Included:
Review of facility policy on 11/16/23 at approximately 8:45am revealed:
"Patient Assessment and Monitoring...During Treatment...3 Machine Parameters and Extracorporeal Circuit...Check machine settings and measurements: check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow...4 Document any findings and interventions in the medical record..."
Review of MR on 11/16/3223 between approximately 9:00am and 4:00pm revealed:
MR2, Admission date 6/14/23, dates reviewed 11/1/23-11/13/23.
11/13/23- Blood Flow Rate (BFR) ordered 400. BFR documented to be 300 for duration of treatment, starting at 12:03pm and ending at 3:22pm. No evidence of documentation to reflect BFR not as per order.
MR3, Admission date 8/18/23, dates reviewed 11/1/23-11/13/23.
11/10/23- Blood Flow Rate (BFR) ordered 400. BFR documented to be 300 for duration of treatment, starting at 6:17am and ending at 10:14am. No evidence of documentation to reflect BFR not as per order.
MR4, Admission date10/24/23, dates reviewed 10/31/23-11/11/23.
11/2/23- Blood Flow Rate (BFR) ordered 300. BFR documented to be 250 starting at 6:31am and ending with treatment at 9:42am. No evidence of documentation to reflect BFR not as per order.
11/7/23- Blood Flow Rate (BFR) ordered 300. BFR documented to be 200 starting at 6:32am and ending with treatment at 9:46am. No evidence of documentation to reflect BFR not as per order.
11/9/23- Blood Flow Rate (BFR) ordered 300. BFR documented to be 250 at 6:32am, 7:04am, and 9:35am. No evidence of documentation to reflect BFR not as per order.
Interview with Director of Operations, Center Manager, and Home Therapies Clinical Manager on November 17, 2023 at approximately 2:00pm confirmed findings.
Plan of Correction:V 544
To ensure compliance the CM or designee will in-service all DPC staff on policy:
- Patient Assessment and Monitoring
Emphasis will be placed on ensuring that any machine parameters not within the physician prescribed limits must be reported to the RN for evaluation, intervention, and documentation. These parameters include the blood flow rate (BFR). The reason the BFR is not being achieved must be documented as well as interventions taken to address the issue. The staff will be instructed that there must be documentation of the RN notification by the patient care technician (PCT).
Inservicing will be completed by December 5, 2023. All training documentation will be on file at the facility.
The CM or designee will perform daily audits of 20% of flowsheets for 4 weeks. At that time, if improved compliance is observed the audits will then be completed 2 times/week for 2 weeks. If 100% compliance is maintained at that time, the audits will be completed monthly following the QAPI program. A POC specific auditing tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audits and report the findings to the QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.
494.90(a)(5) STANDARD
POC-VASCULAR ACCESS-MONITOR/REFERRALS
Name - Component - 00
The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.
Observations:
Based on review of facility policy, Observations (OBS), and staff (EMP) interview the facility failed to ensure staff followed procedure for Post Treatment Fistula Needle Removal for two(2) of two (2) Observations of Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft conducted. (OBS 1 & 2)
Findings Included:
Review of facility policy on 11/16/23 at approximately 8:45am revealed:
"Post Treatment Fistula Needle Removal...Procedure...8. Once hemostasis is achieved: remove the gauze...place Band-Aid, adhesive dressing, or gauze dressing secured with clean tape..."
OBS 1 at station #1, conducted 11/13/23 at approximately 11:10am. EMP1 failed to visualize needle site to ensure hemostasis achieved, failed to remove gauze and place Band-Aid, adhesive dressing, or gauze dressing secured with clean tape. EMP1 placed 2 additional pieces of tape over taped gauze used to hold site.
OBS 2 at station #9, conducted 11/14/23 at approximately 9:25am. EMP6 failed to visualize needle site to ensure hemostasis achieved, failed to remove gauze and place Band-Aid, adhesive dressing, or gauze dressing secured with clean tape. EMP6 placed 2 additional pieces of tape over taped gauze used to hold site.
Interview with Director of Operations, Center Manager, and Home Therapies Clinical Manager on November 17, 2023 at approximately 2:00pm confirmed findings.
Plan of Correction:To ensure compliance the CM or designee will re-educate all DPC staff on the following policies and procedure:
- Post Treatment Fistula Needle Removal
The meeting will emphasize that all staff must visualize the patient's access site to ensure that the bleeding has stopped. The gauze used to achieve hemostasis needs to be disposed of. A new, clean band-Aid, gauze dressing with clean tape or an adhesive dressing needs to be applied once it is verified that the bleeding has stopped.
The staff inservicing will be completed by December 5, 2023. All training documentation will be on file at the facility
The CM or designee will perform daily audits for 2 weeks. At that time if compliance is observed the audits will then be completed 2/week for 2 weeks to ensure that ongoing compliance is maintained. At that time, the audits will then follow the monthly QAPI schedule. A POC specific audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audit results and report the findings to the QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.
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